Healthcare Provider Details

I. General information

NPI: 1457985095
Provider Name (Legal Business Name): TARA VALENZUELA PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2020
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 NORIEGA ST STE 888
SAN FRANCISCO CA
94122-4239
US

IV. Provider business mailing address

7901 4TH ST N STE 300
ST PETERSBURG FL
33702-4399
US

V. Phone/Fax

Practice location:
  • Phone: 843-474-5578
  • Fax: 843-790-1871
Mailing address:
  • Phone: 843-474-5578
  • Fax: 843-790-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN95093148
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number165467
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-3032
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202101780NP-PP
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95014026
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: